What are the next steps for a patient in their late 50s presenting with bloatedness, nausea and vomiting, cold clammy hands, and epigastric abdominal pain?

Immediate Life-Threatening Evaluation Required

This patient requires immediate ECG and cardiac workup to exclude myocardial infarction, as cold clammy hands with epigastric pain, nausea, and vomiting represent a classic atypical cardiac presentation, particularly in patients over 50. 1

Critical Initial Assessment

Rule Out Cardiac Emergency First

• Obtain ECG and troponins immediately before attributing symptoms to gastrointestinal causes, as myocardial infarction commonly presents with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients 1
• Cold, clammy skin suggests sympathetic activation consistent with acute coronary syndrome or other shock states 1
• Cardiac causes carry 10-20% mortality if missed 1

Check for Surgical Emergencies

• Assess vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation or sepsis with high specificity 1
• Sudden severe epigastric pain with fever and abdominal rigidity suggests perforation, which carries 30% mortality if treatment is delayed 1, 2
• Examine for peritoneal signs (rigidity, rebound tenderness) 3

Immediate Diagnostic Workup

Laboratory Tests to Order Now

• Complete blood count, C-reactive protein, serum lactate levels 1
• Serum electrolytes and glucose 1
• Liver and renal function tests 1
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis, with sensitivity and specificity of 80-90% 1

Imaging Considerations

• CT abdomen with IV contrast if perforation suspected, looking for extraluminal gas (97% sensitive), fluid or fat stranding (89%), focal wall defect/ulcer (84%), or wall thickening (72%) 1
• Plain abdominal X-ray may reveal increased stool burden or free air 4

Initial Management While Awaiting Results

Immediate Symptom Control

• Start high-dose proton pump inhibitor therapy immediately: omeprazole 20-40 mg once daily before meals 1, 5
• For nausea relief: ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first due to QTc prolongation risk), promethazine 12.5-25 mg orally/rectally every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours 1
• NPO status until surgical emergency excluded 6
• IV hydration for volume resuscitation given vomiting 6

Differential Diagnosis Algorithm

If Cardiac and Surgical Emergencies Excluded:

Gastroparesis is the leading consideration given the constellation of bloating, nausea, vomiting, and epigastric pain in this age group 4, 7, 8

Features Suggesting Gastroparesis:

• Nausea and vomiting are predominant symptoms 4, 7
• Bloating and early satiety present 4, 7
• Persistent vomiting excludes functional dyspepsia by Rome IV criteria and mandates investigation for structural disease 4, 1
• Approximately 40% of gastroparesis patients report bloating correlating with nausea, abdominal fullness, and pain 4

Features Suggesting Peptic Ulcer Disease:

• Epigastric pain not relieved by antacids 1
• All gastric ulcers require biopsy and histological examination to exclude malignancy 2
• Occult blood in stool, hematemesis indicate bleeding complications 1, 2

Features Suggesting Functional Dyspepsia:

• However, persistent vomiting makes functional dyspepsia unlikely, as Rome IV criteria state this "likely suggests another disorder" 4, 1
• Would require symptoms present for 8 weeks minimum (clinical criteria) 4

Next Steps After Stabilization

If Gastroparesis Suspected:

• Gastric emptying scintigraphy (4-hour study with standardized meal) to confirm delayed gastric emptying 4, 6
• Classify severity as mild, moderate, or severe based on symptoms and emptying study results 4
• Metoclopramide 10 mg three times daily before meals is the only FDA-approved medication for gastroparesis 9, 10, 6
• Consider dietary modifications: small, frequent meals; low-fat, low-fiber diet 6

If Upper Endoscopy Indicated:

• Perform if patient >50 years with new-onset dyspeptic symptoms 4
• Mandatory if alarm features present: persistent vomiting, weight loss, anemia, dysphagia 4, 1
• Biopsy any gastric ulcers to exclude malignancy 2
• Test for Helicobacter pylori if in high-prevalence region 4

Critical Pitfalls to Avoid

• Never dismiss cardiac causes without ECG and troponins in patients >50 with epigastric pain and diaphoresis 1
• Do not attribute persistent vomiting to functional dyspepsia—this mandates structural investigation 4, 1
• Delaying endoscopy in patients with alarm features can lead to poor outcomes 1
• Do not start empiric treatment for gastroparesis without confirming delayed gastric emptying on objective testing 4
• Missing perforation is catastrophic—maintain high suspicion with sudden severe pain, fever, or peritoneal signs 1, 2